INCITE StudyINCITE Study

Co-PI: Frederick Welt, M.D. Co-PI: Daniel I. Simon, M.D.

Brigham and Women’s HospitalWest Roxbury VA Medical Center

Harvard Medical SchoolBoston, MA

INflammatory Cessation with abcIximab or InTEgrilin

INflammatory Cessation with abcIximab or InTEgrilin

INCITE

InflammationInflammationInflammationInflammation AtherosclerosisAtherosclerosisAtherosclerosisAtherosclerosis

ThrombosisThrombosisThrombosisThrombosis

Thrombus

Quiescentplaque

Plateletsand thrombin

Plaque rupture

Acute Coronary Syndromes Evolving Understanding of Pathophysiology

CD40LCD40L

CD40L in Immunity:Isotype Switching

CD40L in Immunity:Isotype Switching

TMTMTNF HomologyTNF HomologyTNF HomologyTNF Homology

Helper T cellHelper T cellHelper T cellHelper T cell B cellB cellB cellB cell

CD40LCD40LCD40LCD40L

sCD40LsCD40LsCD40LsCD40LNNNN CCCC

CD40LCD40LCD40LCD40L CD40CD40CD40CD40

CD40L Distribution

300300

200200

100100

00

CD

40L

Uni

ts/m

L bl

ood

CD

40L

Uni

ts/m

L bl

ood BloodBlood

PlateletsPlatelets LymphocytesLymphocytesCD

40L

Uni

ts/1

x10

CD

40L

Uni

ts/1

x1066

cells

cel

ls

P=P=0.0160.016

CellsCells

PlateletsPlatelets LymphocytesLymphocytes

33

22

11

00

Henn et al., Blood, 2001, 98, 1047Lindmark et al. ATVB, 2000, 20, 2322Andre et al., Nature Med., 2002, 8, 247

CD40L in Vascular Disease• CD40L antibody inhibits atherosclerotic lesion

progression in LDLR -/- mice

• CD40L gene deletion inhibits lesion progression in Apo E-/-mice

• Soluble form detected in ACS and PCI

• Elevated plasma levels of sCD40L identify healthy women at risk for CV events.

• CD40L antibody inhibits atherosclerotic lesion progression in LDLR -/- mice

• CD40L gene deletion inhibits lesion progression in Apo E-/-mice

• Soluble form detected in ACS and PCI

• Elevated plasma levels of sCD40L identify healthy women at risk for CV events.

Nature 1998;391:591Nature 1998;391:591PNAS 2000;97:7458PNAS 2000;97:7458Nature Med 1999;5:1313Nature Med 1999;5:1313

Circulation 1999;100:614Circulation 1999;100:614Circulation 2001;104:2266Circulation 2001;104:2266

Platelet CD40L-Induced Inflammation

thrombinthrombin

CD40LCD40LCD40LCD40L

Cultured HUVECsCultured HUVECs

IL-8IL-8MCP-1MCP-1

ICAM

-1

ICAM

-1

VCAM-1

VCAM-1

TFTF

Modified from: Nature 1998;391:591

sCD40LsCD40L

(min

)

WT

CD40L-/-

CD40 -/

-0

10

20

30

40 *

CD40L-/-

+ rsCD40

L

Time to reach occlusion

sCD40L Promotes Thrombosis:sCD40L Promotes Thrombosis:Delayed Arterial Occlusion in CD40L-/- MiceDelayed Arterial Occlusion in CD40L-/- Mice

30 min after FeCl3

WT

CD40L-/-

* P < 0.0005† P < 0.02

Nature Med, 2002, v.8, 247-52

GP IIb-IIIa Antagonism:GP IIb-IIIa Antagonism: sCD40L Release and AggregationsCD40L Release and Aggregation

00 11 22 33 44 55

125125

100100

7575

5050

2525

00

Eptifibatide (Eptifibatide (M)M)

125125

100100

7575

5050

2525

00

00 0.20.2 0.40.4 0.60.6 0.80.8 11

Tirofiban (Tirofiban (M)M)Abciximab (Abciximab (M)M)

00 0.20.2 0.40.4 0.60.6 0.80.8 11

% s

CD

40L

Rel

ease

% s

CD

40L

Rel

ease

% a

gg

reg

atio

n%

ag

gre

gat

ion

Circulation, Supplement. 2001;104:II-318, 1533

sCD40LsCD40LsCD40LsCD40L

InflammationInflammation

ThrombosisThrombosis

Functions of Released sCD40LFunctions of Released sCD40L

sCD40LsCD40LsCD40LsCD40LGP IIb/IIIa

Abciximab: Anti-Inflammatory Action

AM Lincoff at al. Circ 2001;104:163

GP IIb-IIIa Inhibitors: Specificity/Selectivity

IIb/IIIa xxx xxx xxx

V3 xxx ?x

Mac-1 x

Abciximab Eptifibatide Tirofiban

Charo IF et al. Proc Natl Acad Sci. 1986;83:835Coller BS et al. Blood. 1991;77:75Altieri DC et al. J Immunol. 1988;141:2656Simon DI et al. Arterioscler Thromb Vasc Biol 1997;17:528Lele M et al. Circ 2001;104:582

INCITE: INCITE: HypothesisHypothesis

Our central hypothesis is that GP IIb-IIIa inhibitors will modulate peri-PCI inflammation by virtue of their effect on platelet-induced leukocyte activation.

Our central hypothesis is that GP IIb-IIIa inhibitors will modulate peri-PCI inflammation by virtue of their effect on platelet-induced leukocyte activation.

INCITE

INCITE: INCITE: Study DesignStudy DesignElective PCI

ASA, heparin (50-70 U/kg)Elective PCI

ASA, heparin (50-70 U/kg)

RPFA baseline and 10 min post-bolus

ELISA: sCD40L, RANTES, IL-6, sICAM-1

Timepoints: Baseline, 30 min, 2 hrs, 24 hrs

RPFA baseline and 10 min post-bolus

ELISA: sCD40L, RANTES, IL-6, sICAM-1

Timepoints: Baseline, 30 min, 2 hrs, 24 hrs

NoGP IIb-IIIa

(n=15)

NoGP IIb-IIIa

(n=15)

Abciximab0.25 mg/kg

0.1 g/kg/min(n=15)

Abciximab0.25 mg/kg

0.1 g/kg/min(n=15)

Eptifibatide180/180 g/kg2 g/kg/min

(n=15)

Eptifibatide180/180 g/kg2 g/kg/min

(n=15)

INCITE

Exclusion Criteria-Patients already on GP IIb/IIIa inhibitor-Patients with clear indications for GP IIb/IIIa:

-Acute ST elevation MI or non q-wave MI with CPK elevation

-Pain at rest with EKG changes < 24 hours-Visible Thrombus-Pain refractory to heparin

-Lesions located in vascular grafts or at sites of prior intervention

-Bleeding disorder-Thrombocytopenia (plts< 100)-History of GI bleeding-History of stroke or intracranial bleed-Uncontrolled hypertension (SBP > 200 mm Hg, DBP> 100 mm

Hg)-Condition requiring oral anticoagulation-History of allergy or contraindication for aspirin or heparin

None Abciximab Eptifibatide p-value

n 15 15 15

Age 70.3±11.4 64.3±9.7 61.6±10.8 NS

Diabetes Mellitus, % 20.0 46.7 26.7 NS

Hypertension, % 66.7 80.0 73.3 NS

Elevated Cholesterol, % 66.7 93.3 80.0 NS

Current Smoker, % 26.7 40.0 40.0 NS

Prior MI, % 26.7 53.3 53.3 NS

Prior PCI, % 26.7 53.3 20.0 NS

Prior CABG, % 33.3 46.7 46.7 NS

Unstable Angina, % 20.0 6.7 20.0 NS

WBC 6.6±1.8 7.1±1.9 7.3±2.0 NS

Platelet 223±80 227±61 246±67 NS

Hematocrit 37.1±3.3 37.4±4.1 41.1±3.6 NS

Creatinine 1.1±0.3 1.0±0.2 1.0±0.2 NS

Baseline Characteristics

Procedural Characteristics

None Abciximab Eptifibatide p-value

n 15 15 15

Activated Clotting Time 267±49 287±68 317±55 NS

Platelet Inhibition, % (RPFA)

N/A 93±4 98±3 P<0.01

Multivessel PCI, % 26.7 33.3 40.0 NS

INCITE

Plasma sCD40L Post-PCI

30 min 2 hour 24 hour

ANOVA P=0.018P<0.03 None vs Eptifibatide

-0.1

-0.05

0

0.05

0.1

Del

ta P

lasm

a C

once

ntra

tion

(ng/

ml) None

EptifibatideAbciximab

Plasma RANTES Post-PCI(Pro-inflammatory Platelet derived chemokine)

INCITE

30 min 2 hour 24 hour

ANOVA P=0.006P<0.005 None vs Eptifibatide

-150

-100

-50

0

50

100

De

lta P

lasm

a C

on

cen

tra

tion

(n

g/m

l) None

Eptifibatide

Abciximab

INCITE

Plasma sICAM-1 Post-PCI

30 min 2 hour 24 hour

ANOVA P=0.23

-100

-50

0

50

100

Del

ta P

lasm

a C

once

ntra

tion

(ng/

ml) None

Eptifibatide

Abciximab

INCITE

Plasma IL-6 Post-PCI

30 min 2 hour 24 hourANOVA P=0.1

0

1

2

3

4

5

6

Del

ta P

lasm

a C

once

ntra

tion

(ng/

ml) None

Eptifibatide

Abciximab

SummarySummary

INCITE

GP IIb/IIIa inhibition lowers levels of sCD40L and RANTES post stenting, possibly conferring anti-inflammatory as well as anti-thrombotic effects.

GP IIb/IIIa inhibition lowers levels of sCD40L and RANTES post stenting, possibly conferring anti-inflammatory as well as anti-thrombotic effects.

ConclusionConclusion

INCITE

These findings may have significant implications for long term benefits associated with GP IIb/IIIa inhibitor use.

The findings of this pilot study need to be examined in a larger clinical trial that confirms these findings and correlates reduction in inflammation with improved clinical outcome.

These findings may have significant implications for long term benefits associated with GP IIb/IIIa inhibitor use.

The findings of this pilot study need to be examined in a larger clinical trial that confirms these findings and correlates reduction in inflammation with improved clinical outcome.

Procedural Characteristics

None Abciximab Eptifibatide p-value

n 15 15 15

Activated Clotting Time 267±49 287±68 317±55 NS

Platelet Inhibition, % (RPFA)

N/A 93±4 98±3 P<0.01

Multivessel PCI, % 26.7 33.3 40.0 NS

Platelet aggregation inhibition with abciximab, eptifibatide, and tirofibanPlatelet aggregation inhibition with

abciximab, eptifibatide, and tirofiban

RIAR Study (Keriakes. Am J Cardiol 1999)

tirofiban 0.4/0.1 (n=9)

0

20

40

60

80

100

120

0

20

40

60

80

100

120

0

20

40

60

80

100

120

eptifibatide 180/2 (n=10)

abciximab 0.25/0.125 (n=10)

0.7 2 6 12 24 0.7 2 6 18 240.7 2 6 18 24

Time from bolus (h)

CRP

-20

0

20

40

60

80

Delta

Pla

sm

a C

oncentr

ation (

ng/m

l) None

Integrilin

Reopro

INCITE

Prelim

inar

y Res

ults